Sheridan Garden Assisted Living.

“Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently.     Findings include:     1. A review of E1's personnel record revealed there was no documentation of fall prevention and fall recovery training.   2. In an interview, E2 reviewed and acknowledged that E1's personnel record did not include documentation of fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted on June 2, 2022.”

“Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis infection control activities that included annually assessing its risk of exposure to infectious tuberculosis.   Findings include:   1. A review of the facility’s documentation revealed there was no documentation of an assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. In an interview, E2 acknowledged that the health care institution failed to implement tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical records revealed a service plan, which reflected that R2 received medication administration services. 2. A review of R2's medical record revealed a medication order dated May 21, 2025 for Humalog (Lispro) INS 100 unit/ml pen inject as per sliding scale according to blood sugar: if below 150 administer zero units: 150 through 199 administer one unit; 200 through 249 administer two units; 250 through 299 administer four units; 300 through 349 administer six units; 350 through 399 administer eight units and blood sugar above 400 call primary physician. 3. A review of R2's medical record revealed a medication administration record dated October 2025, which reflected R2 was administered Humalog along with the following documented blood sugar: - 8 am on October 9, 2025, R2’s blood sugar was 153, and was administered two units; - 8 am on October 10, 2025, R2’s blood sugar was 156, and was administered two units; - 8 am on October 11, 2025, R2’s blood sugar was 150, and was administered two units; - 5 pm on October 12, 2025, R2’s blood sugar was 154, and was administered two units; - 5 pm on October 13, 2025, R2’s blood sugar was 181, and was administered two units; - 8 pm on October 13, 2025, R2’s blood sugar was 239, and was administered two units; - 8 pm on October 17, 2025, R2’s blood sugar was 263, and was administered two units; - 8 pm on October 18, 2025, R2’s blood sugar was 253, and was administered two units.  4. In an interview, E2 acknowledged R2’s Humalog was not administered to R2 in compliance with a medication order. This is a repeat deficiency from the compliance inspection conducted on June 2, 2022.”